complaint·January 30, 2023

(Continue...1) R1’s PCP identifies R1 does not have a history of skin breakdown, does not require continuous bed care, and does not have a motor impairment. Assistance is needed with bathing, dressing/grooming, and toileting. In addition, R1 is now noted as a “nearby assist,” regarding transferring. Facility records then show on March 22, 2020, staff observed R1 sustained a skin tear to their lower leg. It is noted R1 was unable to recall when or how it they sustained the injury. In their interview, R1 acknowledged receiving assistance with Activities with Daily Living (ADL) from facility staff, and indicated the facility’s signal system is utilized when assistance is needed. R1 was unable to describe the incident on March 22, 2020, as it occurred. In addition, R1 was observed with no apparent injuries. Their room was clean and kempt, with no obstructions in the walkways. Interviews with staff acknowledge R1 does call for assistance during the evening hours. Staff interviews also indicate the resident will, at times, attempt to get out of bed. When assistance is requested in the evening, staff indicated it is to assist the resident with toileting. Staff acknowledged conducting rounds on the residents, including R1, once every two (2) or three (3) hours. Staff 1 (S1) was identified as the individual who responded to R1 on March 22, 2020. S1 was unable to recall the incident, but indicated what was documented, is what S1 observed; which was R1 was observed with an injury while being assisted with toileting. The injury was cleaned and dressed, and the PCP and responsible party was notified. Based on interviews conducted and pertinent records reviewed, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation occurred. It was also alleged the facility is not reporting incidents as required. The incident that occurred on March 22, 2020, notes R1’s PCP, as well as their responsible party, were notified on March 22, 2020, and March 23, 2020, respectively. Per Regional Office File Review, LPM was unable to locate any other reportable incidents from March, 2020, to May, 2020. (Continue...2) Interviews with staff indicate that if a reportable incident occurs for a resident during the evening shift, responsible parties and PCPs are notified during the AM Shift. The incident that occurred on March 22, 2020, is noted to be reported to R1’s PCP by S1, and R1’s responsible party is noted to be notified by Staff (S2). Interviews with outside sources indicate not being notified timely of incidents for the resident, as they occur. Interviews with R1’s PCP Office, confirmed being notified by the facility, and the residents responsible party, of the incident on March 22, 2020. Based on interviews conducted and pertinent records reviewed, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation occurred. The allegations are determined to be unsubstantiated. The Licensee was provided a copy of their appeal rights (LIC9058 03/22), and their authorized representative’s signature on this form, acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report, along with the appeal rights, was given to Paula Digerness and the conclusion of the visit.